Opioid withdrawal update3[1]

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Opioid withdrawal update3[1]

  1. 1. Opioids
  2. 2. What are opioids? • • • • • Class of drugs which have morphine like effects The effects can be reversed by naloxone CNS depressants Powerful analgesics Prolonged use results in tolerance, less effective analgesic properties
  3. 3. Use & Effects of Opioid Drugs • • • Opioids that bind to receptors & activate them are “agonist” drugs (such as morphine & methadone) Those that bind to receptors but not activate them are “antagonists” (naloxone & naltrexone) Partial agonists (buprenorphine) bind to the same receptors but have less of an activation effect
  4. 4. Harmful Effects Dependence  Amenorrhoea  Infection Scarring, thrombosis, thrombophlebitis Cellulitis, abscess Septicaemia, infective endocarditis, osteomyelitis Blood borne viruses - HIV, HCV(90%), HBV  Overdose-related morbidity symptoms Hypoxic brain injury Rhabdomyolysis  Poly drug and alcohol use highly prevalent 
  5. 5. Types of Opioids available Heroin  Morphine  Oxycontin  Oxycodone  Methadone  Buprenorphine 
  6. 6. History to take • • • • • • • • Name of the drug/s used Dose of the drug (no. of injections per day, dollars spent per day) Route of administration Frequency of use Duration of use Date and time of last use Other drugs used ? Alcohol/ Smoking
  7. 7. Assessing Opioid Use • • • Heroin dosages estimates are difficult - wide variations in the concentration & purity of illicit heroin Oxycontin – More popular than heroin Consumption may be recorded as: The no of injections / day The no of grams ingested Dollars spent
  8. 8. Assessing Opioid Use Approximate guide to a patient’s level of opioid use: Low end = 1 to 2 injections / day, OR = 0.5 gram heroin or less / day High end = 4 + injections / day, OR = 1-2 grams heroin or more / day
  9. 9. Signs and Symptoms of opioid intoxication  Analgesia  Euphoria  Miosis (‘pinned’ pupils)  Constipation  Sedation  Itching, red eyes (histamine release)  Respiratory depression and reduced cough reflex  Decreased level of consciousness (‘on the nod’)  Hypotension/bradycardia
  10. 10. Other Clinical Presentations General – cachexia,  CV – Murmurs, Pulse pressure, stigmata of IE  GE - CLD / hemetemesis  Respiratory – LRTI /COPD  Neuro - Septic Embolus /Discitis  ID – Cellulitis /Abcesses / Sepsis/ BBV 
  11. 11. Investigations UDS  Bloods including FBC, LFTs, UEC, BBV (consent please)  BAC  CXR  ECG 
  12. 12. Opioid Overdose Drowsy  Decrease in GCS  Decrease in O2 saturations  Respiratory depression  Rx: 400 mcg of Naloxone initially as test dose and then further 400 mcg of naloxone  Consider alternative dx if failure to respond 
  13. 13. Unplanned Withdrawal • Patients in hospital, prison or other institutional care may undergo unplanned opioid withdrawal • Patients may not always reveal their opioid use
  14. 14. Withdrawal Syndrome Opioid Time after last dose Sx appear Duration withdrawal syndrome (days) Heroin / Morphine / IV oxycontin 6 – 24 hours 5 – 10 days Pethidine 3 – 4 hours 4 – 5 days Methadone 36 – 48 hours 3 – 6 weeks Buprenorphine 3 – 5 days Up to several weeks Kapanol / MS Contin (if intravenous) 8 – 24 hours 7 – 10 days Codeine PO 8 – 24 hours 5 – 10 days
  15. 15. Duration of opioid withdrawal • Following acute withdrawal, protracted, low-grade symptom of discomfort (psychological & physical) may last many months
  16. 16. Signs & Symptoms of Opioid Withdrawal Symptoms Anorexia & nausea Abdominal pain Hot & cold flushes Bone, joint & muscle pain Insomnia & disturbed sleep Cramps Intense craving Signs Restlessness Yawning Perspiration Rhinorrhoea Dilated pupils Piloerection Muscle twitching – restless legs when lying down Vomiting Diarrhoea
  17. 17. Course of Opioid withdrawal NSW Department of Health (2007).
  18. 18. Withdrawal Monitoring • Patients should be monitored regularly & this may include use of a withdrawal scale • Frequency of observations should be determined by the severity of the withdrawal • Monitoring should be based on observations, objective signs & subjective Sx
  19. 19. Withdrawal Scales • The Clinical Opiate Withdrawal Scale (COWS) rates 11 items describing severity of symptoms from scores of 0 (not present) to > 36 (severe) • The COWS is considered a reliable & valid withdrawal scale
  20. 20. Withdrawal Scales • Withdrawal scales do NOT diagnose withdrawal, but merely guides to the severity of an already diagnosed withdrawal syndrome • Re-evaluate the patient regularly to ensure that it is opioid withdrawal & not underlying medical condition, especially if the patient is not responding well to Rx
  21. 21. Opioid Withdrawal Rx • An opioid withdrawal syndrome can be managed with: Buprenorphine Methadone Symptomatic Meds
  22. 22. Buprenorphine • A partial opioid agonist – an opioid analgesic with both agonist and antagonist properties • Available in 2 forms: buprenorphine & bup/naloxone (Suboxone film) • Administered sublingually (tab usually take 5 minutes to dissolve, film adheres within 90 secs) • Less respiratory depression than full agonists
  23. 23. Buprenorphine • Buprenorphine is the principal Rx option for managing opioid withdrawal • Well suited in the hospital setting • Can effectively relieve symptom severity in opioid withdrawal, meaning that other symptomatic medication may not be required
  24. 24. Buprenorphine • • • - Buprenorphine binds very tightly to opioid receptors & can displace other opioids Buprenorphine can precipitate withdrawal 1st doses bup should be delayed for at least 6 hours after heroin & oxy 24 hours after methadone NB: buprenorphine is NOT to be administered until withdrawal is evident
  25. 25. Buprenorphine • If using a withdrawal scale as part of patient assessment Rx should not begin until: A COWS score of a least 8 (representing the mid point of scale) Give 2mg buprenorphine (test dose) If tolerated, can give a further 4-8mg in 1 hour Pt can have a total of 32mg Day 1 if clinically indicated
  26. 26. Methadone “Gold standard” pharmacotherapy for opioid dependence for over 30 years  Synthetic opioid with a long half life  Administered daily  Dispensed from a clinic, hospital or registered pharmacy  Authorised prescribers  Clients are registered with NSW Pharmaceutical Services Unit 
  27. 27. Methadone to Treat Opioid W/D Maximum initiation dose 40mg/d (in consultation with D&A Team)  Usually 15mg BD in hospital in initiation  Usually increase every 3/7’s  Commonly used in patients who have opioid analgesia requirements  D&A Team always offer to link patient in with community OST  Patient may or may not want ongoing OST 
  28. 28. Symptomatic Mx for Opioid Withdrawal Muscles Aches / Pains Paracetamol 1000mg, every 4 hours PRN (maximum 4000mg in 24 hours OR Ibuprofen 400mg 6 hourly PRN (if no Hx of peptic ulcer or gastritis) Nausea Metoclopramide 10mg, 4-6 hourly PRN, reducing to 8th hourly as Sx reduce OR Prochlorperazine (Stemetil) 5mg, every 4-6 hours PRN, reducing to 8th hourly as Sx reduce 2nd line Rx for severe nausea/vomiting: Ondansetron (Zofran) 4-8mg, every 12 hours PRN
  29. 29. Symptomatic Mx for Opioid Withdrawal Abdominal cramps Hyoscine (buscopan) 20mg, every 6 hours PRN 2nd line Rx for severe gastrointestinal Sx: Octreotide (sandostatin) 0.05-0.1mg, every 812 hours PRN by subcutaneous injection (hospital setting only) Diarrhoea Kaomagma or loperamide (gastro-stop) 2mg PRN
  30. 30. Symptomatic Mx for Opioid Withdrawal Sleeplessness Temazepam 10-20mg nocte. Cease dose after 3-5 nights Agitation / Anxiety Diazepam 5mg QID PRN Restless legs Diazepam (as above) OR Baclofen 10-25mg every 8 hours Sweating, sedating agitation Clonidine 75mcg every 6 hours
  31. 31. Altered tolerance and pain management Analgesics should not be withheld unless medically indicated  Providing pain relief will not make the patient more drug dependent  Methadone patients will not receive pain relief from their usual daily dose  First indication of tolerance to opioids is decreased duration of effect, decreased analgesia – an involuntary physiological response 
  32. 32. Opioid maintenance treatment in hospital Patients who are on methadone or buprenorphine when admitted to SVH should remain on their current dose – UNLESS THEY HAVE MISSED DOSES – PLS RING D&A • PSU – 9424 5921  Confirm last dose from the dosing point  Remove takeaway doses from patient if they are on their person  Ensure adequate pain relief is given  Dosing point will need fax of last dose on D/C •
  33. 33. Buprenorphine & Pt’s in Acute Pain….  Standard doses of opioid analgesia are not likely to be effective in any patient who has taken buprenorphine within the last 3-4 days  Non opioid analgesia, local anaesthetics approaches, higher dose opioid prescriptions, ceasing or increasing bup may be required for pain relief – Contact D&A & APS
  34. 34. Buprenorphine / methadone prescribing… • In hospital, doctors can prescribe methadone or buprenorphine as part of management of opioiddependent people • Outside hospital, methadone & buprenorphine may only be used in the treatment of opioid dependency by authorised medical practitioners
  35. 35. Take Home Take a good substance use history  Screen for BBV  Rx with naloxone in suspected od with 400 mcg x 2  Rx opioid withdrawal with suboxone or methadone 

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